This paper examines some of the evidence linking structural factors to HIV risk; research gaps, including the pathways through which factors affect HIV vulnerability and interaction among factors; and explores the advantages of taking a “structurally informed” approach to HIV planning and implementation, namely the value of influencing clustered risk factors, the potential to influence multiple outcomes, and opportunities for co-financing. The authors argue that attention to structural forces that either heighten HIV vulnerability or create AIDS resiliency is an important but under-researched and under-programmed area of HIV prevention. There is long-standing evidence that demonstrates that a variety of social forces have both direct and indirect effects on HIV transmission, and undermine the effectiveness of proven biomedical prevention programmes. Intervening “upstream” yields multiple benefits: it allows programmes to potentially affect multiple risk factors at once (especially when they cluster), and it offers promise to influence a range of health and development outcomes through a single intervention. The authors argue that structural approaches to HIV prevention are an efficient and effective strategy in our current era of global fiscal austerity.
Equity and HIV/AIDS
While global guidance for HIV prevention recognises the importance of structural HIV prevention, evidence for the effectiveness of these interventions, and their implementation, are lagging behind other areas of prevention. The challenges to implementation at the community and national levels are less well understood. This paper examines the United States (US) President’s Emergency Plan for AIDS Relief (PEPFAR)/US Agency for International Development (USAID) experience with implementing structural interventions in Zambia. Despite challenges to implementing, monitoring, and evaluating structural interventions, they can and have been implemented successfully and are necessary for a long-term and sustained response to both HIV and social and economic development needs, the authors argue. Better identification of causal pathways, involvement of key stakeholders and collaborators, and enhanced monitoring will strengthen implementation of structural interventions and provide the necessary data to understand their outcomes and impacts. Such efforts and stronger links between structural interventions and other biomedical and behavioural interventions will result in a true combination approach to HIV prevention, yielding better results.
According to this report, one reason that HIV prevention efforts have not kept pace has been insufficient attention to HIV’s “structural factors”, namely those areas beyond individual knowledge or awareness that shape risk and vulnerability to infection. Examples are often context-specific but can include economic inequality and livelihood insecurity, as well as hunger, gender inequality, and lack of education. These factors, many of which are rooted in various formal and informal types of marginalisation, underpin the diversity of HIV epidemics, helping to explain why some countries have a higher HIV burden than others. Structural factors have been demonstrated to influence treatment access and retention. The authors argue that action on structural factors can have multiple beneficial impacts not only on HIV-related goals but also on other health, development and human rights objectives. Implementing structural approaches requires a range of disciplinary perspectives that extend beyond the health sector, as well as cross-sector governance and financing.
The aim of this study was to assess the effectiveness of a community-based natural resource management programme that “mainstreamed” HIV awareness and prevention activities within rural communities in Namibia. The authors used data from two rounds of the Namibia Demographic and Health Surveys (2000 and 2006/2007), including a total of 117 men and 318 women in 2000, and 170 men and 357 women in 2006/2007. They found that community-based conservation in Namibia has significantly reduced multiple sexual partnerships, the main behavioural determinant of HIV and AIDS infection in Africa. They argue that their results demonstrate the effectiveness of holistic community-based approaches centred on the preservation of lives and livelihoods, and highlight the potential benefits of integrating conservation and HIV prevention programming in other areas of communal land tenure in Africa.
Kenya’s National AIDS Control Council (NACC) and the National AIDS and STI Control Programme (NASCOP) have launched an HIV and AIDS strategy for transport corridors that aims to reach out to high-risk mobile populations along transport corridors. It will help ensure provision of effective HIV and sexually transmitted infection (STI) prevention, treatment, care and support programmes for truckers, female sex workers, and men who have sex with men along with the communities they interact with such as border officials, police officers and the general population. The strategy will further provide a national framework within which HIV programming can be realised by various stakeholders providing HIV services along the transport corridors in Kenya.
In this paper, the authors describe lifetime prevalence of consensual male–male sexual behaviour and male-on-male sexual violence (victimisation and perpetration) in two South African provinces, socio-demographic factors associated with these experiences, and associations with HIV serostatus. The study was conducted in 2008 and included men aged 18–49 from randomly selected households in the Eastern Cape and KwaZulu-Natal provinces, who provided anonymous survey data and dried blood spots for HIV serostatus assessment. Interviews were completed in 1,737 of 2,298 (75.6%) of enumerated and eligible households. In this sample, one in 20 men (5.4%) reported lifetime consensual sexual contact with a man, while about one in ten (9.6%) reported experience of male-on-male sexual violence victimisation. Men who reported having had sex with men were more likely to be HIV+, as were men who reported perpetrating sexual violence towards other men. Whilst there was no direct measure of male–female concurrency (having overlapping sexual relationships with men and women), the data suggest that this may have been common. These findings suggest that HIV prevention messages regarding male–male sex in South Africa should be mainstreamed with prevention messages for the general population, and sexual health interventions and HIV prevention interventions for South African men should explicitly address male-on-male sexual violence.
There is emerging data from Southern Africa that key populations such as female sex workers (FSW) carry disproportionate burden of HIV; however, their burden of HIV and prevention needs remains unknown in Swaziland. To address this gap, a respondent-driven-sampling survey was completed between August and October, 2011 of 328 FSW in Swaziland. Unadjusted HIV prevalence was found to be 70.3% among a sample of women predominantly from Swaziland with a mean age of 21, which was significantly higher than the general population of women. Just 23.5% reported always wearing condoms with sexual partners in the past month, while rape was common at 40% reporting at least one rape, with torture reported at 53.2%. While Swaziland has a highly generalised HIV epidemic, FSW represent a distinct population with a high burden of HIV compared to other women, according to the authors. These women are understudied and underserved resulting in a limited characterisation of their HIV prevention, treatment, and care needs and only sparse targeted programming. The authors argue that FSW are an important population for further investigation and rapid scale-up of combination HIV prevention including biomedical, behavioural and structural interventions.
The authors of this study investigated factors associated with patterns of plural healthcare usage among patients taking antiretroviral therapy (ART) in diverse South African settings. They conducted a cross-sectional study of ART patients in two rural and two urban sub-districts, involving 13 accredited facilities and 1,266 participants selected through systematic random sampling. They used structured questionnaires in interviews and reviewed participant’s clinic records. Results showed that 19% of respondents reported use of additional healthcare providers over and above their regular ART visits in the prior month. Increased plural healthcare utilisation, inequitably distributed between rural and urban areas, was found to be largely a function of higher socioeconomic status, better ability to finance healthcare and factors related to poor quality of care in ART clinics. Healthcare expenditure of a catastrophic nature remained a persistent complication. Although plural healthcare utilisation did not appear to influence clinical outcomes, there were potential negative impacts on the livelihoods of patients and their households.
This study aims to demonstrate changes in population level HIV mortality in two high HIV prevalence slums in Nairobi with respect to the initiation and subsequent scale up of the national antiretroviral therapy (ART) programme. The authors used data from 2070 deaths of people aged 15–54 years that occurred between 2003 and 2010 in a population of about 72,000 individuals living in two slums covered by the Nairobi Urban Health and Demographic Surveillance System. Results indicated that, overall, HIV mortality declined significantly from 2.5 per 1,000 person years in the early period to 1.7 per 1,000 person years in the late period. The risk of dying from HIV was 53% less in the late period compared to the period before, controlling for age and gender. Women experienced a decline in HIV mortality between the two periods that was more than double that of men. At the same time, the risk of non-HIV mortality did not change significantly between the two time periods. In conclusions, population-level HIV mortality in Nairobi’s slums was significantly lower in the approximate period coinciding with the scale-up of ART provision in Kenya. However, further studies that incorporate ART coverage data in mortality estimates are needed. Such information will enhance our understanding of the full impact of ART scale-up in reducing adult mortality among marginalised slum populations in Kenya.
In a previous issue of the Southern African Journal of HIV Medicine, Pillay and Black summarised the trade-offs of the safety of efavirenz use in pregnancy. Highlighting the benefits of the World Health Organisation’s proposed options for the prevention of mother-to-child transmission (PMTCT) of HIV, the authors argued that the South African government should adopt Option B as national PMTCT policy and pilot projects implementing Option B+ as a means of assessing the individual- and population-level effect of the intervention. The authors of this article echo this call and further propose that the option to remain on lifelong antiretroviral therapy, effectively adopting PMTCT Option B+, be offered to pregnant women following the cessation of breastfeeding, for their own health, following the provision of counselling on associated benefits and risks. Here they highlight the benefits of Options B and B+.